MaxAvSafety: WKLY Accident/Incident Report Update 11/26/17

MaxSez: This Rpt updates the report of 11/23 which was published early in error.
This Rpt will return to its regular Sunday release subsequently:

Saturday Nov 25th 2017
Accident Starbow AT72 at Accra on Nov 25th 2017, runway excursion during takeoff
Incident Getjet B734 near Vilnius on Nov 25th 2017, indication of gear anomaly
Incident Indigo A320 at Delhi on Nov 22nd 2017, smoke in cockpit
Accident Eva B773 near Fukuoka on Nov 22nd 2017, turbulence injures 12
Friday Nov 24th 2017
Incident Malaysia B738 enroute on Nov 7th 2017, sauna in flight
Incident Aeroflot B773 enroute on Nov 21st 2017, a bugged sensor and autothrottle
Incident Canada Rouge B763 at Toronto on Nov 16th 2017, runway incursion
Report Skytraders A319 at Melbourne on May 15th 2015, push buttons, human perceiption and a descent below minimum safe altitude
(Source: AvHerald)

Significant:

1). Accident: Eva B773 near Fukuoka on Nov 22nd 2017, turbulence injures 12
By Simon Hradecky, created Friday, Nov 24th 2017 23:37Z, last updated Saturday, Nov 25th 2017 00:16Z
An Eva Airways Boeing 777-300, registration B-16718 performing flight BR-56 from Taipei (Taiwan) to Chicago O’Hare,IL (USA) with 178 passengers and 21 crew, was enroute at FL310 about 180nm eastsoutheast of Fukuoka (Japan) when the aircraft encountered turbulence causing altitude deviations of +375 and -550 feet, the speed over ground varied between 600 and 568 knots. The aircraft stabilized at FL310 and continued to Chicago for a safe landing about 11 hours later. One cabin crew received serious injuries, 3 passengers and 8 cabin crew minor injuries.

Taiwan’s ASC reported one cabin crew received serious, 3 passengers and 8 cabin crew received minor injuries. The ASC have opened an investigation into the occurrence.

The airline reported a passenger with medical qualification took care of the injured in flight. The injured were taken to a hospital after landing.END

  1. Incident: Malaysia B738 enroute on Nov 7th 2017, sauna in flight
    By Simon Hradecky, created Friday, Nov 24th 2017 23:16Z, last updated Friday, Nov 24th 2017 23:16Z
    A Malaysia Airlines Boeing 737-800, registration 9M-MXG performing flight MH-605 from Kuala Lumpur (Malaysia) to Singapore (Singapore), climbed to FL230 enroute and was enroute when the passengers on board felt increasingly hot, complaints were raised with cabin crew and the captain. The flight continued to Singapore for a safe landing about 40 minutes after departure.

A passenger reported the aircraft was already uncomfortably warm during boarding as if it had been parked in sunshine and window shades open without air conditioning for a considerable time. After the departure the temperature increased even further, the air conditioning vents provided a very light flow of hot air instead of cool air. About 15 minutes into the flights the passengers began to complain to cabin crew while cabin crew was serving refreshments, cabin crew referred to the captain. About 30 minutes the passengers became loud complaining about the uncomfortable temperatures. Several passengers used the safety cards and inflight magazines of the aircraft as a fan. Reaching the top of descent the captain announced that they were working on the cabin temperature, it remained uncomfortably hot however. After landing the passenger used a thermometer and still received an indication of 95.4 degrees Fahrenheit=35.2 degrees C.

The occurrence aircraft remained on the ground for about 92 hours, then returned to service.END

3).Final Accidant Rpt: Report: Skytraders A319 at Melbourne on May 15th 2015, push buttons, human perceiption and a descent below minimum safe altitude
By Simon Hradecky, created Friday, Nov 24th 2017 18:19Z, last updated Friday, Nov 24th 2017 18:23Z
A Skytraders Airbus A319-100, registration VH-VCJ performing flight SND-2 from Perth,WA to Melbourne,VI (Australia) with 18 passengers and 5 crew, was on approach to Melbourne’s runway 16 via the WENDY 1A standard arrival route, the captain (ATPL, 17,250 hours total, 2,835 hours on type) was pilot flying, the first officer (also ranked Captain, ATPL, 12,290 hours total, 2,200 hours on type) was pilot monitoring. Autopilot 1, modes NAV and (managed) DESCENT, and autothrust were engaged, the aircraft turned left at waypoint NEFER descending towards cleared 3000 feet (3000 feet active in the FCU). While descending through 4700 feet the flaps were selected to and reached stage 1. The aircraft rolled wings level after the turn heading towards BOL. When descending through 3600 feet the captain announced to “arm the approach”, which would have resulted in pushing the APPR push button on the FCU, however, accidentally the captain pushed the button EXPED. The autopilot changed to expeditious open descent mode, the vertical speed increased from 800 to 1600 fpm with 220 KIAS remaining constant. A few seconds later the first officer spotted the changed flight mode and pointed out the incorrect mode change. In an attempt to correct the mistake the captain now pressed the A/THR push button effectively selecting the autothrust function off resulting in a THRUST LOCK condition with according announciation on both PFDs, ECAM, an aural alert and a master caution. The first officer recognized the condition and pointed it out. At the same time the autopilot changed to ALT* (altitude acquire). The captain recognized the Thrust Lock condition and pressed both “instinctive disconnect” buttons on the side stick and thrust levers with the intention to reduce the airspeed and retard the thrust levers. The disconnect disconnected the autopilot, the cavalry sound activted for one second, the THRUST LK condition disconnected. As the thrust levers were still in the CLB detent, the commanded thrust changed from idle to climb, the engines began to accelerate. The captain re-engaged the autopilot, however, did not reconnect autothrust. Due to the rapidly accelerating thrust the captain began to provide nose down inputs on the side stick (in post flight interviews he stated he did not recall any nose down input but recalled he had the impression the aircraft was pitching up), due to the nose down input the autopilot disconnected again, the cavalry charge sounded for one second. The captain moved the thrust levers to idle, the aircraft accelerated through 240 KIAS and the first officer queried whether he should retract the flaps affirmed by the captain, the flaps were retracted. The rate of descent rapidly increased, the altitude alerter sounded (C-Chord) for 15 seconds, the engines spooled down and the captain began to provide nose up inputs, the rate of descent stabilized, then began to decrease. EGPWS sounded “SINK RATE” twice, the thrust levers were placed fully forward and the captain announced they were going around. The engines responded and began to accelerate, the EGPW sounded “TERRAIN AHEAD, PULL UP, TERRAIN AHEAD”, due to the now rapidly increasing thrust the captain again changed to provide nose down inputs, the aircraft continued to descend. EGPWS sounded “TERRAIN! TERRAIN! PULL UP!”, the captain now provided nose up inputs and the aircraft began to climb while the first officer radioed ATC, that they were going around. The lowest altitude was recorded at 2200 feet MSL, 1100 feet AGL, during the flaps retraction the aircraft reached its maximum speed at 314 KIAS. At the ATC desk the minimum safe altitude warning (MSAW) activated, the controller saw the aircraft descending through 2300 feet and starting to climb again at 2200 feet. ATC cleared the aircraft to climb to 4000 feet, then informed the crew the MSAW had activated. While the aircraft positioned for another approach the aircraft was cleared to climb to 5000 feet, subsequently joined the ILS for runway 16 and landed safely.

Australia’s ATSB released their final report concluding the probable causes of the serious incident were:

  • The pilot flying inadvertently selected the EXPED pushbutton instead of the APPR pushbutton, and, in an attempt to correct the error, pressed the A/THR pushbutton, creating a thrust lock condition.

  • In attempting to remove the thrust lock condition, the pilot flying pressed the instinctive disconnect pushbutton but did not move the thrust levers to match the locked thrust setting. As the thrust was locked at idle while the thrust levers were set to climb thrust, this resulted in an unexpected, significant thrust increase.

  • The pilot flying likely experienced pitch-up illusions during two rapid thrust increases and responded to these illusions with pitch-down sidestick input.

  • Pitch-down inputs by the pilot flying, combined with a very high thrust setting, resulted in a very high rate of descent with rapidly increasing airspeed. This led to the breach of the cleared minimum descent altitude, as well as triggering a number of Enhanced Ground Proximity Warning System alerts.

  • The rapidly changing aircraft state led to the crew experiencing a high workload. This was likely to have limited their capacity to identify mode changes and to respond to the aircraft’s undesired high airspeed and rate of descent.

  • The pilot monitoring’s ability to identify and influence the rapidly changing situation was likely affected by the non-routine actions of the pilot flying, the reduced communication between flight crew and an apparent focus on the flap speed exceedance as the aircraft started to accelerate. END

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Interesting one at the end there… thanks for sharing!

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